Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people: systematic review and economic evaluation

Background: Psoriasis is a chronic inflammatory disease that predominantly affects the skin. Adalimumab (HUMIRA®, AbbVie, Maidenhead, UK), etanercept (Enbrel®, Pfizer, New York, NY, USA) and ustekinumab (STELARA®, Janssen Biotech, Inc., Titusville, NJ, USA) are the three biological treatments currently licensed for psoriasis in children. Objective: To determine the clinical effectiveness and cost-effectiveness of adalimumab, etanercept and ustekinumab within their respective licensed indications for the treatment of plaque psoriasis in children and young people. Data sources: Searches of the literature and regulatory sources, contact with European psoriasis registries, company submissions and clinical study reports from manufacturers, and previous National Institute for Health and Care Excellence (NICE) technology appraisal documentation. Review methods: Included studies were summarised and subjected to detailed critical appraisal. A network meta-analysis incorporating adult data was developed to connect the effectiveness data in children and young people and populate a de novo decision-analytic model. The model estimated the cost-effectiveness of adalimumab, etanercept and ustekinumab compared with each other and with either methotrexate or best supportive care (BSC), depending on the position of the intervention in the management pathway. Results: Of the 2386 non-duplicate records identified, nine studies (one randomised controlled trial for each drug plus six observational studies) were included in the review of clinical effectiveness and safety. Etanercept and ustekinumab resulted in significantly greater improvements in psoriasis symptoms than placebo at 12 weeks’ follow-up. The magnitude and persistence of the effects beyond 12 weeks is less certain. Adalimumab resulted in significantly greater improvements in psoriasis symptoms than methotrexate for some but not all measures at 16 weeks. Quality-of-life benefits were inconsistent across different measures. There was limited evidence of excess short-term adverse events; however, the possibility of rare events cannot be excluded. The majority of the incremental cost-effectiveness ratios for the use of biologics in children and young people exceeded NICE’s usual threshold for cost-effectiveness and were reduced significantly only when combined assumptions that align with those made in the management of psoriasis in adults were adopted. Limitations: The clinical evidence base for short- and long-term outcomes was limited in terms of total participant numbers, length of follow-up and the absence of young children. Conclusions: The paucity of clinical and economic evidence to inform the cost-effectiveness of biological treatments in children and young people imposed a number of strong assumptions and uncertainties. Health-related quality-of-life (HRQoL) gains associated with treatment and the number of hospitalisations in children and young people are areas of considerable uncertainty. The findings suggest that biological treatments may not be cost-effective for the management of psoriasis in children and young people at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year, unless a number of strong assumptions about HRQoL and the costs of BSC are combined. Registry data on biological treatments would help determine safety, patterns of treatment switching, impact on comorbidities and long-term withdrawal rates. Further research is also needed into the resource use and costs associated with BSC. Adequately powered randomised controlled trials (including comparisons against placebo) could substantially reduce the uncertainty surrounding the effectiveness of biological treatments in biologic-experienced populations of children and young people, particularly in younger children. Such trials should establish the impact of biological therapies on HRQoL in this population, ideally by collecting direct estimates of EuroQol-5 Dimensions for Youth (EQ-5D-Y) utilities. Study registration: This study is registered as PROSPERO CRD42016039494. Funding: The National Institute for Health Research Health Technology Assessment programme

Acceptability and HIV Prevention Benefits of a Peer-Based Model of Rapid Point of Care HIV Testing for Australian Gay, Bisexual and Other Men Who Have Sex with Men

© 2017, The Author(s). Frequent HIV testing among gay, bisexual and other men who have sex with men (GBM) is a strategic priority for HIV prevention in Australia. To overcome barriers to testing in conventional clinical services, Australia recently introduced peer HIV rapid point of care (RPOC) testing services for GBM. This mixed methods evaluation describes client acceptability and HIV prevention benefits of a peer HIV testing model. Most aspects of the service model were overwhelmingly acceptable to clients. Two-thirds of survey participants reported preferring testing with peers rather than doctors or nurses and over half reported learning something new about reducing HIV risk. Focus group findings suggested peer-delivered HIV RPOC testing reduced stigma-related barriers to frequent testing and provided novel opportunities for GBM to openly discuss HIV prevention and sexual practices, enhancing their HIV risk-reduction knowledge. Analysis of survey data suggested knowledge transfer occurred particularly among younger and less gay community-attached GBM

Yield Losses in Transgenic Cry1Ab and Non-Bt Corn as Assessed Using a Crop-Life-Table Approach

In this study, we constructed crop life tables for Bacillus thuringiensis Berliner (Bt) Cry1Ab and non-Bt corn hybrids, in which yield-loss factors and abundance of predaceous arthropods were recorded during 2 yr at two locations. Corn kernel/grain was the yield component that had the heaviest losses and that determined the overall yield loss in the corn hybrids across years and locations. Yield losses in both corn hybrids were primarily caused by kernel-destroying insects. Helicoverpa zea (Boddie) and Spodoptera frugiperda (Smith) (Lepidoptera: Noctuidae) were the key loss factors at one location, while at the other, the key loss factor was the silk fly larvae, Euxesta spp. (Diptera: Ulidiidae). Although the realized yield of corn grains was not different (P > 0.05) between Cry1Ab and non-Bt corn hybrids, the Bt corn hybrid reduced (P < 0.05) the damage by H. zea and S. frugiperda in three of the four field trials, particularly at the location where Lepidoptera were the key loss factors. As expected, no reduction in the abundance of predaceous arthropods was observed in Cry1Ab corn fields. Various species of natural enemies were recorded, particularly the earwig Doru luteipes (Scudder) (Dermaptera: Forficulidae), which was the most abundant and frequent predaceous insect. These results indicate that integration of pest management practices should be pursued to effectively minimize losses by kernel-destroying insects during corn reproductive stages when growing non-Bt or certain low-dose Bt corn cultivars for fall armyworm and corn earworm, such as those producing Cry1Ab or other Cry toxins